LECTURE NOTE ON EPIDEMIOLOGY

FOR

LAUTECH NURSING STUDENTS

NSG 317

COMPILED BY;

AKINLOYE KEHINDE (RN, Bnsc)

COURSE OUTLINE

Definition of epidemiology

Principle and methods of epidemiology as they apply to the study of

communicable and non-communicable disease

Types of epidemiological studies and clinical application

Key concepts in epidemiology

Core epidemiological functions

Disease causation in epidemiology

Epidemiological measurement
INTRODUCTION

The study of disease and injury distribution and causes in the human
population is known as epidemiology. It is a branch of science that studies the
incidence, distribution, and quality of health in human populations. Studies using
an epidemiological approach can be used for any illness, condition, or incident
involving health.
In the past, epidemiology has had a significant influence on national health. Its
beginnings can be roughly dated to the era of Hippocrates (460–377 BC), a
physician who made an effort to rationally study the causes of illness (Valanis,
1992).
The relevance of epidemiological research in assessing population health is
enormous. Traditionally, epidemiology has been thought of as a field related to
public health and medicine. Nowadays, it's evident that many other health-related
areas use and adapting it for their own purposes and reaping its benefits.
The word epidemiology comes from the Greek words epi, meaning “on or upon,”
demos, meaning “people,” and logos, meaning “the study of.”

DEFINITIONS

Many definitions have been proposed, but the following definition captures the
underlying principles and the public health spirit of epidemiology:

“Epidemiology is the study of the distribution and determinants of health-related

states or events in specified populations, and the application of this study to the
control of health problems.”
Epidemiology is a discipline which has evolved with the changes taking place in
society and the emergence of new diseases and new discipline related to
epidemiology. With these evolutions, it is important to understand epidemiology
and to analyze the evolution of content of definitions of epidemiology.

Epidemiology is the foundation of public health and is defined as the study of the
“distribution and determinants” of diseases or disorders within groups of people,
and the development of knowledge on how to prevent and control
them. Epidemiological research helps us understand not only who has a disorder or
disease but why and how it was brought to this individual or region.(WHO)

Epidemiology is the “study of distribution and determinants of health-related states

among specified populations and the application of that study to the control of
health problems.”—a textbook of epidemiology

Epidemiology is "The study of the occurrence and distribution of health-related

events, states, and processes in specified populations, including the study of the
determinants influencing such processes, and the application of this knowledge to
control relevant health problems

Epidemiology may be defined as the study of the distribution of health and disease
in groups of people and the study of the factors that influence this distribution.
Modern epidemiology also encompasses the evaluation of diagnostic and
therapeutic modalities and the delivery of health-care services.

Epidemiology concerns describing and understanding patterns of disease

occurrence in human populations, with the ultimate goal of preventing disease

The Objectives Of Epidemiology Include The Ability To:

 Identify the etiology or cause of disease

  Determine the extent of disease
 Study the progression of the disease
 Evaluate preventive and therapeutic measures for a disease or condition
 Develop public health policy

Uses of Epidemiology

1. To study the disease trend since past

2. Community diagnosis

3. Planning and evaluation of health services

4. Evaluation of a new therapy or a new health measure

5. Determining the risk to an individual

6. Identification of syndromes

7. Filling in the gaps in the natural history of the disease

8. Searching for the cause of a disease

METHODS IN EPIDEMIOLOGY

There are two main branches analytical and descriptive epidemiology—work to

decrease health events and diseases by understanding the risk factors for them.
Both branches serve public health organizations by providing information that may
reduce disease and other kinds of events affecting human health.

 Descriptive epidemiology it’s a specialty that evaluates and catalogs all the
circumstances surrounding a person affected by a particular health event.
The more fully a descriptive epidemiologist can describe people, places and
times, and any correlations between the three, the more likely it is that
 patterns will emerge which can be considered risk factors for certain kinds
of health issues.
In descriptive epidemiology, scientists examine and describe in detail the
people, places and times related to public health events, in order to
understand and reduce health risks. They consider the impact of
demographic, geographic and socioeconomic factors. They also take into
account behavioral influences such as diet, work schedule, exercise
frequency, drug use and sexual habits, all of which may influence a person’s
health and health risk.
They ask questions known as the five Ws:
What (is the health event or diagnosis)?
When (did the health event occur)?
Where (did it take place?
Who (are the people involved and affected)?
Why/how (did it happen)?
 Analytical epidemiologists use the data gathered by descriptive
epidemiologists to look for patterns that suggest causes.

PRINCIPLES OF EPIDEMIOLOGY

This definition of epidemiology includes several terms which reflect some of the
important principles of the discipline. As you study this definition, refer to the
description of these terms below which is common to all the definitions stated
above.

Study; Epidemiology is a scientific discipline, sometimes called “the basic science

of public health.” It has, at its foundation, sound methods of scientific inquiry.
Distribution; Epidemiology is concerned with the frequency and pattern of health
events in a population. Frequency includes not only the number of such events in a
population, but also the rate or risk of disease in the population. The rate (number
of events divided by size of the population) is critical to epidemiologists because it
allows valid comparisons across different populations.

Pattern refers to the occurrence of health-related events by time, place, and

personal characteristics.

• Time characteristics include annual occurrence, seasonal occurrence, and daily or

even hourly occurrence during an epidemic.

• Place characteristics include geographic variation, urban-rural differences, and

location of worksites or schools.

• Personal characteristics include demographic factors such as age, race, sex,

marital status, and socioeconomic status, as well as behaviors and environmental
exposures.

This characterization of the distribution of health-related states or events is one

broad aspect of epidemiology called descriptive epidemiology. Descriptive
epidemiology provides the What, Who, When, and Where of health-related events.

Determinants; Epidemiology is also used to search for causes and other factors
that influence the occurrence of health-related events. Analytic epidemiology
attempts to provide the Why and How of such events by comparing groups with
different rates of disease occurrence and with differences in demographic
characteristics, genetic or immunologic make-up, behaviors, environmental
exposures, and other so-called potential risk factors. Under ideal circumstances,
epidemiologic findings provide sufficient evidence to direct swift and effective
public health control and prevention measures.
Health-related states or events; originally, epidemiology was concerned with
epidemics of communicable diseases. Then epidemiology was extended to
endemic communicable diseases and no communicable infectious diseases. More
recently, epidemiologic methods have been applied to chronic diseases, injuries,
birth defects, maternal-child health, occupational health, and environmental health.
Now, even behaviors related to health and well-being (amount of exercise, seat-
belt use, etc.) are recognized as valid subjects for applying epidemiologic methods.
“Disease” refers to the range of health-related states or events.

Specified populations; although epidemiologists and physicians in clinical

practice are both concerned with disease and the control of disease, they differ
greatly in how they view “the patient.” Clinicians are concerned with the health of
an individual; epidemiologists are concerned with the collective health of the
people in a community or other area. When faced with a patient with diarrheal
disease, for example, the clinician and the epidemiologist have different
responsibilities. Although both are interested in establishing the correct diagnosis,
the clinician usually focuses on treating and caring for the individual. The
epidemiologist focuses on the exposure (action or source that caused the illness),
the number of other persons who may have been similarly exposed, and the
potential for further spread in the community, and interventions to prevent
additional cases or recurrences.

Application; Epidemiology is more than “the study of.” As a discipline within

public health, epidemiology provides data for directing public health action.
However, using epidemiologic data is an art as well as a science. To treat a patient,
a clinician must call upon experience and creativity as well as scientific
knowledge. Similarly, an epidemiologist uses the scientific methods of descriptive
and analytic epidemiology in “diagnosing” the health of a community, but also
must call upon experience and creativity when planning how to control and prevent
disease in the community.

APPLICATION OF EPIDEMIOLOGY TO THE STUDY OF

COMMUNICABLE AND NON COMMUNICABLE DISEASE

Concepts in Communicable Disease

The following concepts are very important in understanding communicable disease.
Incubation Period: this is the period between the exposure to an infectious agent and the
appearance of the first signs and symptoms of disease.

It is worthy of note here that the (d) point is the variable which is the outcome and could be the
patient going into convalescence, chronic illness or death can occur.
Characteristics of organisms that influence diseases/illness formation
There are characteristics that influence disease/illness formation in the body. These are:
 Infectivity
 Pathogenicity
 Virulence
 Antigenic Power.
Resistance
This is the sum total of body mechanism that provides a barrier to the progress of invasion or
multiplication of infectious agents and damage their toxic products. This is made possible
through immunity.
Carrier
A carrier is someone who though has disease causing organism in his body but does not show
any sign of infection. The carrier has the ability to harbor and disseminate the parasite without
showing any clinical evidence of infection. There are times when even carriers of a disease are
more than those showing the signs of the disease. They often become chronic carriers but this
does not last long. Some of the disease known to have carriers include: cholera, salmonella typhi,
poliomyelitis and diphtheria.
Types of Carrier
1. Incubatory carrier is one that is transferred during incubation period
2. Convalescent carrier is one that is transferred during recovery period
3. Intermittent carrier is one that is on and off
4. Chronic carrier is one in which the individual keeps carrying the disease on for a long time
5. Healthy carrier is someone who does not show the manifestation at any time but keeps on
transmitting it to people.
Immunity
This is the resistance usually associated with possession of antibodies having specific actions on
the micro-organism concerned with a particular infectious disease or its toxin. An individual is
considered immune when he possesses specific protective antibodies or cellular immunity as a
result of previous infection or immunisation or by previous experience. Immunity can be natural
or acquired. Natural is inherent in the individual or specie and it is independent of previous
infection. Acquired immunity can be active and passive. Active acquired immunity can be
natural or induced, while passive acquired may be natural/trans-placental or passive induced.
Active Immunity: this is the immunity an individual develops as a result of infection or specific
immunisation and usually associated with antibodies or cells having a specific action on the
disease or toxin. This can be acquired through any of the following:
After infection e.g. measles
After in-apparent infection e.g. poliomyelitis
After immunisation
Passive Immunity: this is the transference of antibodies produced in one body to another to
induce protection against disease. This is useful for individual who cannot form antibodies or for
the normal host who takes time to develop antibodies after active immunisation. Here, the body
depends solely on ready-made antibodies. This can be derived from any of the following:
When an antibody is administered
Transfer of maternal antibodies across the placenta
Transfer of lymphocytes to induce passive cellular immunity.
Herd Immunity: this is the level of resistance of a community or group of people to a particular
disease. It provides an immunological barrier to the spread of disease in the human herd.
Vaccine: this is an immuno-biological substance designed to produce specific protection against
a given disease. It stimulates the production of protective antibody and other immune
mechanisms. It may be prepared from live modified mechanism or inactivated or killed
organisms.
Concept of the Non-communicable Diseases
Non-communicable disease is an illness that occurs due to a specific causative agent or its toxic
products but not transferable from persons to persons. It may be acute or chronic. Our discussion
here will cover the chronic diseases. This will include all ailments or deviation from normal
which have one or the following characteristics:
 Permanent disability leaves residual disability
 Caused by non-reversible pathological change
 It requires the special training of the patient for rehabilitation
 It may be expected to require a long period of supervision, observation and care.
With the control of communicable disease in some part of the world, a change occurs in the
demographic picture leading to an older population. This is why chronic disease has become the
commonest cause of morbidity and mortality. An estimated 43% of all DALYs(Disability-
Adjusted Life Years; is a measure that extends the concept of potential years of life lost due to
premature death to include equivalent years of healthy life lost by virtue of being in states of
poor health or disability.) globally were attributable to non-communicable diseases. However in
low and middle income countries the figure was 39%, while in high income countries was 81%.
Non-communicable diseases include cardiovascular, renal, nervous and mental diseases,
musculoskeletal conditions such as arthritis and allied diseases, chronic non-specific respiratory
diseases (e.g. chronic bronchitis, emphysema, and asthma), permanent results of accidents,
senility, blindness, cancer, diabetes, and obesity and various other metabolic and degenerative
diseases and chronic results of communicable diseases. Disorders of unknown cause and
progressive cause and often labeled “degenerative”.

TYPES OF EPIDEMIOLOGICAL STUDIES AND CLINICAL

APPLICATIONS

In epidemiology, researchers are interested in measuring or assessing the

relationship of exposure with a disease or an outcome. As a first step, they define
the hypothesis based on the research question and then decide which study design
will be best suited to answer that question. How the researcher conducts the
investigation is directed by the chosen study design. The study designs can be
broadly classified as experimental or observational based on the approach used to
assess whether exposure and an outcome are associated

Epidemiological studies comprises of the following:

1. Descriptive Epidemiology study

This is the study of the frequencies and distribution of a disease within a

population by persons, place and time. The three broad questions necessary to
describe the occurrence of a disease fully relating to persons, place and time
are: Person-who is getting the disease (person characteristics)? i.e. male or
female, the age range, ethnicity, marital status, social and economic factors,
social class, education, occupation, income level, family variables such as size,
type, birth order, maternal age, parental deprivation and personal habits. Place-
 where is it occurring (place characteristics)? This will answer for region, state,
district, LGA, local community, towns, village and wards either in the city or
rural areas. Boundaries are also considered with precise location. Time-when is
the disease occurring (time characteristics)? This includes the year, season, and
day of the week, month and the time of the day. Certain diseases are common
during the year for example measles in dry season.

The procedures in descriptive studies are:

o Defining the population to be studied

o Defining the disease under study
o Describing the disease by: time, place and person
o Measurement of disease
o Comparing with known indices
o Formulation of an etiological hypothesis.

a. Cross Sectional Study (Prevalence) with individuals as a unit

b. Longitudinal (Incidence)

2. Analytical Epidemiology study

This is the second major type of epidemiological studies. While descriptive studies
look at the entire population, analytic studies only look at the individuals so
affected within the population. The focus is not to formulate but to test hypothesis.
However, even though individuals are evaluated in analytical studies, the inference
is made in respect of the population so selected. Analytical studies comprises of
two distinct types of observational studies. These are: retrospective or case study
and prospective or cohort study. From here, we can determine whether or not a
statistical association exists between a disease and a suspected factor and if it does,
what is the strength of association. In prospective or cohort studies, a group of
persons are exposed to causative factors while others are not. A follow-up is made
in the nearest future to check the proportion of effects on the exposed and the non-
exposed and comparism is then made.

a. Case-control (Case-reference) with individuals as unit of study

b. Cohort (absolute, relative, attributable risk or follow-up with individuals as unit

of study)

3. Experimental / Interventional Studies

This is a study in which one group deliberately subjected to an experience is

compared with a control group which has not had a similar experience. The use of
experimental study is done with ethical considerations. It usually involves selection
of an individual or communities. The principle of conducting experimental trials is
that under the control of the investigator, some system is subjected to
manipulation, creating an independent variables whose effect is then determined by
the measurement of subsequent events or outcome this is known as the dependent
variable.

a. Randomized controlled trials/or Clinical trials with patients as unit of study

b. Field trials or community intervention studies with healthy people as unit of

study

c. Community trials with communities as unit of study.

3 Observational Studies

This is made up of the descriptive and analytical studies

 STEPS IN THE INVESTIGATION OF AN EPIDEMIC

1. Determine that an epidemic or outbreak actually exists by comparing with previous data on
the disease

2. Establish an etiologic diagnosis if possible; if not, define the condition epidemiologically

and clinically. Collect materials for isolation and serological test, and data from sick and well-
exposed persons

3. Investigate the extent of the outbreak by a quick survey of hospitals, physicians, and other
sources and its basic epidemiological characteristics in terms of time, place, person, probable
method of spread, and the spectrum of clinical illness. Prepare a spot map of cases and an
epidemic curve. Call in outside help if needed

4. Formulate a working hypothesis of the source and manner of spread as a basis for further
study

5. Test the hypothesis by determining infection and illness rates in persons exposed or not
exposed to putative source(s) of infection by questionnaire, interview, and laboratory tests. Try
to isolate the agent from the putative source(s)

6. Extend epidemiological and laboratory studies to other possible cases or to persons exposed
but not ill

7. Analyze the data and consider possible interpretations

8. On the basis of the analysis, initiate both short- and long-term control measures

9. Report the outbreak to appropriate public health officials

10. Inform physicians, other health officials, and the public of the nature of the outbreak and
the ways to control it

KEY CONCEPTS IN EPIDEMIOLOGY

Attack rate or case ratio: This ratio expresses incidence rates in population groups
during specified time periods or under special circumstances such as in an
epidemic. It is often expressed as a percent (cases per 100).

Secondary attack rate is the proportion of persons who develop infection within an
appropriate incubation period after exposure to a primary case divided by the
number exposed. The groups so exposed are frequently family members or persons
located in an institution.

Carrier: A carrier is a person, animal, or arthropod who harbors a specific

infectious agent in the absence of clinical illness with or without a detectable
immune response. The carrier state may reflect carriage of the organism in the
incubation period before clinical symptoms appear, during an apparent or in
apparent infection (healthy or asymptomatic carrier), or following recovery from
illness; it may be of short or long duration (chronic carrier), and it may be
intermittent or continuous. Carriers may spread the infectious agent to others.
Case-fatality rate: Number of deaths of a specific disease divided by the number of
cases × 100.

Chemoprophylaxis: Administration of a chemical or antibiotic to prevent infection

or to prevent the development of disease in a person already infected.

Colonization: Multiplication of an organism on a body surface (e.g., skin,

epithelium, mucus membrane) without evoking a tissue or immune response.

Communicable period: Time during which a person (or animal) is infectious for
another person, animal, or arthropod.

Endemic: This term denotes the constant or usual presence of an infection or

disease in a community. A high degree of endemicity is termed hyperendemic, and
one with a particularly high level of infection beginning early in life and affecting
most of the population is called holoendemic.

Epidemic: An epidemic or outbreak is said to exist when an unusual number of

cases of a disease occur in a given time period and geographic area as compared
with the previous experience with that disease in that area. For diseases already
present in the community, it is necessary to know the number of existing cases
(prevalence) as well as new cases (incidence) to determine whether an increase has
occurred. The definition of increases or excess cases is arbitrary and will vary from
disease to disease.

Host: A person, animal (including birds), or arthropod in which infectious agents

subsist or infect under natural conditions.
Health; A state of complete physical, mental, and social well-being and not merely
the absence of disease or infirmity.

Immunity: The specific resistance to an infectious agent resulting from humoral

and local antibodies and from cell-mediated responses constitutes immunity.
Immunity may be acquired through natural infection, by active immunization, by
transfer of immune factors via the placenta, or by passive immunization with
antibodies from another person or animal. The immune state is relative and not
absolute, is governed largely through genetic control, and may be altered by
disease- or drug-induced immunosuppression.

Immunodeficiency: A state representing impairment of the immune system of the

host that affects its ability to respond to a foreign antigen. This may result from an
inherited defect, or an acquired one such as a result of the disease itself, or of
immunosuppressive drugs or an infectious agent that depresses the immune
system. The human immunodeficiency viruses (HIV-1 and HIV-2) are the major
examples of the latter.

Incidence rate: The number of new events (specific infection or disease) occurring
in a given time period in a given population as the numerator and the number of
susceptible persons in that population exposed to the agent as the denominator.
This is usually stated as cases (or infections) per 100, 1,000, or 100,000.

Incubation period: The incubation period is the interval between exposure and the
appearance of the first detectable sign or symptom of the illness.

Index case: This is the index or primary case of an illness in a family, group,
institution, or community that may serve as a source of infection to others.
Infection: Infection represents the deposition, colonization, and multiplication of a
microorganism in a host and is usually accompanied by an immune response.
Infection may occur with or without clinical illness.

Isolation: This is a term applied to the separation of infected persons in such places
and/or under such conditions as to prevent contact or airborne transmission of the
infectious agent to others during the period of communicability.

Morbidity rate: An incidence rate in which the numerator includes all persons
clinically ill in a defined time and population and the denominator is the population
involved or a subunit thereof, usually expressed as the number of cases per
100,000 persons at risk.

Mortality rate: The same as morbidity rate except the numerator consists of deaths.
This may be the total number of deaths in a population group (crude mortality rate,
usually expressed as deaths per 1,000) or deaths from a specific disease (disease-
specific mortality, usually expressed as deaths per 100,000).

Nosocomial infections: This term refers to infections that develop after entry into a
hospital or other health care institutions and that are not present or incubating at
the time of admission or the residual of an infection acquired during a previous
admission.

Pathogenicity: The ability of an infectious agent to produce disease in a susceptible

host. Some nonpathogenic agents can become pathogenic in an
immunocompromised host such as persons infected with HIV.
Pandemic; An epidemic occurring over a very wide area (several countries or
continents) and usually affecting a large proportion of the population.

Prevalence rate: The ratio of the number of persons in a defined population who
are affected with the disease at any one time as the numerator and the exposed
population at that point as the denominator.

Quarantine: The restriction of persons or animals exposed to an infected source

during the incubation period for that disease to observe if the disease develops in
order that other persons will not be exposed to the infectious agent during that
period.

Reservoir: A person, animal, soil, or other environment in which an infectious

agent normally exists and multiplies and which can be a source of infection to
other hosts.

Surveillance: As concerns public health, surveillance is the systematic collection of

data pertaining to the occurrences of specific diseases or health-related conditions,
the analysis and interpretation of these data, and the dissemination of consolidated
and processed information to contributors to the program and other interested
persons for purposes of control and/or prevention.

Serological surveillance is the identification of current and past infection through

measurement of antibody or of antigen in serum from representative samples of the
population or other target groups.

Susceptibility: A state in which a person or animal is capable of being infected with

a microorganism. The lack of specific protective antibody usually indicates
 susceptibility to that agent, although reactivation or reinfection to some agents may
occur in the presence of antibody.

Transmission: The mechanism by which an infectious agent is spread to another

host.

Virulence: A measure of the degree of pathogenicity of an infectious agent as

reflected by the severity of the disease produced and its ability to invade the tissues
of the host.

Vector; An animate intermediary in the indirect transmission of an agent that

carries the agent from a reservoir to a susceptible host.

Vehicle; An inanimate intermediary in the indirect transmission of an agent that

carries the agent from a reservoir to a susceptible host.

Vital statistics; systematically tabulated information about births, marriages,

divorces, and deaths, based on registration of these vital events.

Zoonosis: An infection or infectious disease transmissible under natural conditions

from animals to man. It may be endemic (enzootic) or epidemic (epizootic).

CORE EPIDEMIOLOGICAL FUNCTIONS

1. Monitoring Public Health

The ongoing collection, analysis, interpretation and dissemination of health data to help guide
decision making and action about public health in public health monitoring. This is one of the
core functions of epidemiology.
The goal of public health surveillance, also known as information for action, is to describe
ongoing epidemics and potential epidemics for which investigation, control, and prevention
measures can be applied effectively. These tasks are accomplished through the systematic
collection and evaluation of morbidity and mortality reports and related health information.
Disseminate and interpret these data to those involved in disease control and public health
decision-making.
Mortality and morbidity reports are a common source of surveillance data for state and local
health departments. These reports are typically submitted by healthcare providers, infection
control physicians, or laboratories that are required to notify the medical department of any
patient with a reportable illness, such as whooping cough, meningococcal meningitis or AIDS .
Other health-related data sources used for surveillance include reports from individual case and
disease cluster investigations, public health program data such as immunization coverage in the
community , disease registration and public health surveys.

2. Investigate The Scene

One of the first jobs that comes out of a surveillance case report or a cluster report is an
investigation by the public health department. The investigation may be limited to a phone call to
a healthcare provider to confirm or clarify reported cases, or it may involve a field investigation.
Requires a concerted effort by those involved to describe the extent of the epidemic and to
determine its cause.
Investigations often aim to identify more people with unreported or unrecognized illnesses who
may go on to infect others. For example, one of the hallmarks of investigating people with STIs
is the identification of the patient's sexual partner or relationship. When interviewed, many of
these people were found to be infected without knowing it and received the treatment they didn't
realize they needed. Identifying and treating these conditions prevents the condition from
spreading.
In some cases, the goal of an investigation may be simply to learn more about the natural history,
clinical spectrum, descriptive epidemiology, and risk factors of the disease before determining
what interventions might be appropriate?
Early investigation of the 2003 SARS outbreak is needed to establish case definitions based on
clinical presentation and characterizing at-risk populations over time, location, and person. As
more is understood about the epidemiology of the disease and its transmissibility, appropriate
recommendations regarding isolation and quarantine have been issued.

3. Analytical Research
To determine the cause and mode of transmission and control measures, appropriate disease
prevention is often close to surveillance and field investigation. However, some other analytical
studies need to use more rigorous methods. This is necessary.
Often methods are used in combination - with surveillance and field investigations providing
clues or hypotheses about the causes and modes of transmission, while analytical studies assess
the reliability of that hypothesis.
Frequent outbreaks or clusters are initiated with descriptive epidemiology. Descriptive methods
involve the study of disease incidence and spread over time, place, and person. This includes
calculating rates and identifying parts of the population that are at higher risk than others.
Sometimes, when the association between exposure and disease is quite strong, the investigation
can be stopped when the descriptive epidemiology is complete and control measures can be
implemented immediately.
John Snow's 1854 cholera survey is an example. Descriptive studies, like case investigations,
generate hypotheses that can be tested by analytical studies. While some fieldwork is being
carried out in response to acute health problems such as epidemics, more studies are planned.
Characteristic of an analytic epidemiological study is the use of a valid comparison group.
Epidemiologists must be skilled in all aspects of such studies, including the design, conduct,
analysis, interpretation, and communication of results.
Design includes determining the appropriate study strategy and study design, justifications and
protocols, calculating sample size, deciding on criteria for subject selection (e.g. developing
definition case), select the appropriate comparison group and design the questionnaire. Conduct
related to ensuring proper clearance and approval, following appropriate ethical principles,
abstracting records, tracking and interviewing subjects, collecting and handling specimens, and
data management. The analysis begins with characterization of the subjects, proceeds to the
calculation of proportions, the creation of comparison tables, and the calculation of measures of
association, tests of significance, confidence intervals. Most epidemiological studies require
 more advanced analytical techniques such as stratified analysis, regression, and modeling.
Finally, interpret the information relevant to the study results, in order to provide sound
messages and recommendations.

4. Evaluation of Public Health Services and Other Health Activities is an important role of
epidemiology. Evaluation is the process of determining as systematically and objectively as
possible, the suitability, effectiveness and impact of activities in relation to stated objectives.

Effectiveness refers to the outcome of a medical program that produces the intended results; this
efficiency is the ability to produce results under ideal conditions. Effectiveness refers to the
outcome of a health program that produces the intended results with minimal cost of time and
resources. The assessment itself can focus on plans (process assessment), activities (process
assessment), impact (summary audit) or results - or any combination of these.
For example, evaluating immunization programmes, can assess the effectiveness of activities, the
proportion of the target population immunized, and the apparent impact of the program on the
incidence of preventable diseases, vaccine preventable.
Similarly, evaluating a surveillance system can address the system's operations and attributes, its
ability to detect cases or outbreaks, and its usefulness.

5. Linking Relevant Agencies

Epidemiologists working in public health settings rarely act alone. In fact, field epidemiology is
often thought of as a team sport. In an investigation, an epidemiologist often participates as a
member or leader of a multidisciplinary team.
Other team members may be workers, hygienists, infection control personnel, nurses or other
clinical staff, and may include computer information specialists.
Many outbreaks cross both geographic regions and jurisdictions, so investigators may come from
local, state or federal levels of government, academic institutions, clinical settings. In order to
foster current and future inter-agency collaboration, epidemiologists need to maintain
relationships with staff from other agencies and organizations.
6. Policy Development
The most important function in epidemiology is the application of these studies to the control of
health-related problems. Epidemiologists generally understand a problem and the scale of the
epidemic in which it occurs is often in a qualified position to recommend appropriate
interventions.
As a result, public health epidemiologists regularly provide input, testimony, and
recommendations regarding disease control strategies, reportable disease regulation, and policy
in health care.

DISEASE CAUSATION IN EPIDEMIOLOGY

Disease is usually considered the opposite of health, a deviation from the normal function. Webster
defines disease as “a condition in which body health is impaired, a departure from a state of health, and
alteration of the human body interrupting the performance of vital functions”. However, from an
ecological view, disease is defined as “a maladjustment of the human organism to the environment”.

i. Theories of the pre-modern era

ii. Germ theory of disease
iii. Biomedical model
iv. Epidemiological triad
v. Dever’s epidemiological model
vi. Theory of multifactorial causation
vii. Web of Causation
viii. Wheel of disease causation
ix. Other theories - Lazaru’s theories of stress response - Wolf’s theory of stress, organ
maladaptation and disease - Holmes and Rahe’s theory of life change and the onset of illness

EPIDEMIOLOGICAL TRIAD

A number of models of disease causation have been proposed. Among the simplest of these is the
epidemiologic triad or triangle, the traditional model for infectious disease. The triad consists of an
external agent, a susceptible host, and an environment that brings the host and agent together. In this
model, disease results from the interaction between the agent and the susceptible host in an
environment that supports transmission of the agent from a source to that host. Two ways of depicting
this model are shown in Figure below.

Agent, host, and environmental factors interrelate in a variety of complex ways to produce disease.
Different diseases require different balances and interactions of these three components. Development
of appropriate, practical, and effective public health measures to control or prevent disease usually
requires assessment of all three components and their interactions.

Epidemiologic Triad

Agent originally referred to an infectious microorganism or pathogen: a virus, bacterium,

parasite, or other microbe. Generally, the agent must be present for disease to occur; however,
presence of that agent alone is not always sufficient to cause disease. A variety of factors
influence whether exposure to an organism will result in disease, including the organism’s
pathogenicity (ability to cause disease) and dose.

Over time, the concept of agent has been broadened to include chemical and physical causes of
disease or injury. These include chemical contaminants (such as the L-tryptophan contaminant
responsible for eosinophilia-myalgia syndrome), as well as physical forces (such as repetitive
mechanical forces associated with carpal tunnel syndrome). While the epidemiologic triad serves
as a useful model for many diseases, it has proven inadequate for cardiovascular disease, cancer,
and other diseases that appear to have multiple contributing causes without a single necessary
one.

Host refers to the human who can get the disease. A variety of factors intrinsic to the host,
sometimes called risk factors, can influence an individual’s exposure, susceptibility, or response
to a causative agent. Opportunities for exposure are often influenced by behaviors such as sexual
practices, hygiene, and other personal choices as well as by age and sex. Susceptibility and
response to an agent are influenced by factors such as genetic composition, nutritional and
immunologic status, anatomic structure, presence of disease or medications, and psychological
makeup.

Environment refers to extrinsic factors that affect the agent and the opportunity for exposure.
Environmental factors include physical factors such as geology and climate, biologic factors
such as insects that transmit the agent, and socioeconomic factors such as crowding, sanitation,
and the availability of health services.

CAUSAL THEORY (Rothman’s causal pie)

An individual factor that contributes to cause disease is shown as a piece of a pie, like the
triangles in the game Trivial Pursuit. After all the pieces of a pie fall into place, the pie is
complete, and disease occurs. The individual factors are called component causes. The complete
pie, which is termed a causal pathway, is called a sufficient cause. A disease may have more
than one sufficient cause, with each sufficient cause being composed of several component
causes that may or may not overlap. A component that appears in every single pie or pathway is
called a necessary cause, because without it, disease does not occur. An example of this is the
role that genetic factors play in haemophilia in humans – haemophilia will not occur without a
specific gene defect, but the gene defect is not believed to be sufficient in isolation to cause the
disease.

An example: Note in the image below that component cause A is a necessary cause because it
appears in every pie. But this should not mean that it is the “root cause”, because it is not
sufficient on its own.
 Rothman’s Causal Pies

CHAIN OF DISEASE CAUSATION

No matter the germ, there are six points at which the chain can be broken and a germ can be
stopped from infecting another person. The six links include: the infectious agent, reservoir,
portal of exit, mode of transmission, portal of entry, and susceptible host.

 Infectious agent is the pathogen (germ) that causes diseases

 Reservoir includes places in the environment where the pathogen lives (this includes
people, animals and insects, medical equipment, and soil and water)
  Portal of exit is the way the infectious agent leaves the reservoir (through open wounds,
aerosols, and splatter of body fluids including coughing, sneezing, and saliva)

 Mode of transmission is the way the infectious agent can be passed on (through direct or
indirect contact, ingestion, or inhalation)

 Portal of entry is the way the infectious agent can enter a new host (through broken skin,
the respiratory tract, mucous membranes, and catheters and tubes)

 Susceptible host can be any person (the most vulnerable of whom are receiving
healthcare, are immunocompromised, or have invasive medical devices including lines,
devices, and airways)

The way to stop germs from spreading is by interrupting this chain at any link. Break the chain
by cleaning your hands frequently, staying up to date on your vaccines (including the flu shot),
covering coughs and sneezes and staying home when sick, following the rules for standard and
contact isolation, using personal protective equipment the right way, cleaning and disinfecting
the environment, sterilizing medical instruments and equipment, following safe injection
practices, and using antibiotics wisely to prevent antibiotic resistance.

IMPORTANT ASPECTS INVOLVED IN THE CHAIN OF ANY INFECTION.

1. ETIOLOGIC AGENT

The etiologic agent may be any microorganism that can cause infection. The pathogenicity of an
agent is its ability to cause disease; pathogenicity is further characterized by describing the
organism's virulence and invasiveness. Virulence refers to the severity of infection, which can be
expressed by describing the morbidity (incidence of disease) and mortality (death rate) of the
infection. An example of a highly virulent organism is Yersinia pestis, the agent of plague, which
almost always causes severe disease in the susceptible host.

The invasiveness of an organism refers to its ability to invade tissue. Vibrio cholerae organisms
are noninvasive, causing symptoms by releasing into the intestinal canal an exotoxin that acts on
the tissues. In contrast, Shigella organisms in the intestinal canal are invasive and migrate into
the tissue.
No microorganism is assuredly a virulent. An organism may have very low virulence, but if the
host is highly susceptible, as when therapeutically immunosuppressed, infection with that
organism may cause disease. For example, the poliomyelitis virus used in oral polio vaccine is
highly attenuated and thus has low virulence, but in some highly susceptible individuals it may
cause paralytic disease.

Other factors should be considered in describing the agent. The infecting dose (the number of
organisms necessary to cause disease) varies according to the organism, method of transmission,
site of entrance of the organism into the host, host defenses, and host species. Another agent
factor is specificity; some agents (for example, Salmonella typhimurium) can infect a broad
range of hosts; others have a narrow range of hosts. Styphi, for example, infects only humans.
Other agent factors include antigenic composition, which can vary within a species (as in
influenza virus or Streptococcus species); antibiotic sensitivity; resistance transfer plasmids; and
enzyme production.

The reservoir of an organism is the site where it resides, metabolizes, and multiplies. The source
of the organism is the site from which it is transmitted to a susceptible host, either directly or
indirectly through an intermediary object. The reservoir and source can be different; for example,
the reservoir for S typhi could be the gallbladder of an infected individual, but the source for
transmission might be food contaminated by the carrier. The reservoir and source can also be the
same, as in an individual who is a permanent nasal carrier of S aureus and who disseminates
organisms from this site. The distinction can be important when considering where to apply
control measures.

2. METHOD OF TRANSMISSION

The method of transmission is the means by which the agent goes from the source to the host.
The four major methods of transmission are by contact, by common vehicle, by air or via a
vector.

 Direct contact transmission the agent is spread directly, indirectly, or by airborne

droplets. Direct contact transmission takes place when organisms are transmitted directly
from the source to the susceptible host without involving an intermediate object; this is
 also referred to as person-to-person transmission. An example is the transmission of
hepatitis A virus from one individual to another by hand contact.
 Indirect transmission occurs when the organisms are transmitted from a source, either
animate or inanimate, to a host by means of an inanimate object. An example is
transmission of Pseudomonas organisms from one individual to another by means of a
shaving brush. Droplet spread refers to organisms that travel through the air very short
distances, that is, less than 3 feet from a source to a host. Therefore, the organisms are not
airborne in the true sense. An example of a disease that may be spread by droplets is
measles.

Common-vehicle transmission refers to agents transmitted by a common inanimate

vehicle, with multiple cases resulting from such exposure. This category includes
diseases in which food or water as well as drugs and parenteral fluids are the vehicles of
infection. Examples include food-borne salmonellosis, waterborne shigellosis, and
bacteremia resulting from use of intravenous fluids contaminated with a gram-negative
organism.

 Airborne transmission, refers to infection spread by droplet nuclei or dust. To be truly

airborne, the particles should travel more than 3 feet through the air from the source to
the host. Droplet nuclei are the residue from the evaporation of fluid from droplets, are
light enough to be transmitted more than 3 feet from the source, and may remain airborne
for prolonged periods. Tuberculosis is primarily an airborne disease; the source may be a
coughing patient who creates aerosols of droplet nuclei that contain tubercle bacilli.
Infectious agents may be contained in dust particles, which may become resuspended and
transmitted to hosts. An example occurred in an outbreak of salmonellosis in a newborn
nursery in which Salmonella-contaminated dust in a vacuum cleaner bag was
resuspended when the equipment was used repeatedly, resulting in infections among the
newborns.
 The fourth method of transmission is vector borne transmission, in which arthropods are
the vectors. Vector transmission may be external or internal. External, or mechanical,
transmission occurs when organisms are carried mechanically on the vector (for
example, Salmonella organisms that contaminate the legs of flies). Internal transmission
 occurs when the organisms are carried within the vector. If the pathogen is not changed
by its carriage within the vector, the carriage is called harborage (as when a flea ingests
plague bacilli from an infected individual or animal and contaminates a susceptible host
when it feeds again; the organism is not changed while in the flea). The other form of
internal transmission is called biologic. In this form, the organism is changed biologically
during its passage through the vector (for example, malaria parasites in the mosquito
vector).

An infectious agent may be transmitted by more than one route. For

example, Salmonella may be transmitted by a common vehicle (food) or by contact spread
(human carrier). Francisella tularensis may be transmitted by any of the four routes.

3. Host

The third link in the chain of infection is the host. The organism may enter the host through the
skin, mucous membranes, lungs, gastrointestinal tract, or genitourinary tract, and it may enter
fetuses through the placenta. The resulting disease often reflects the point of entrance, but not
always: meningococci that enter the host through the mucous membranes may nonetheless cause
meningitis. Development of disease in a host reflects agent characteristics (see above) and is
influenced by host defense mechanisms, which may be nonspecific or specific.

Nonspecific defense mechanisms include the skin, mucous membranes, secretions, excretions,
enzymes, the inflammatory response, genetic factors, hormones, nutrition, behavioral patterns,
and the presence of other diseases. Specific defense mechanisms or immunity may be natural,
resulting from exposure to the infectious agent, or artificial, resulting from active or passive
immunization.

The environment can affect any link in the chain of infection.

 Temperature can assist or inhibit multiplication of organisms at their reservoir;

 air velocity can assist the airborne movement of droplet nuclei;
 low humidity can damage mucous membranes;
 Ultraviolet radiation can kill the microorganisms.
In any investigation of disease, it is important to evaluate the effect of environmental factors. At
times, environmental control measures are instituted more on emotional grounds than on the
basis of epidemiologic fact. It should be apparent that the occurrence of disease results from the
interaction of many factors. Some of these factors are outlined here.

THE DETERMINANTS OF HEALTH INCLUDE

 The social and economic environment,

 The person’s individual characteristics and behaviours.

 Income and social status - higher income and social status are linked to better health. The
greater the gap between the richest and poorest people, the greater the differences in
health.

 Education – low education levels are linked with poor health, more stress and lower self-
confidence.

 Physical environment – safe water and clean air, healthy workplaces, safe houses,
communities and roads all contribute to good health. Employment and working
conditions – people in employment are healthier, particularly those who have more
control over their working conditions

 Social support networks – greater support from families, friends and communities is
linked to better health. Culture - customs and traditions, and the beliefs of the family and
community all affect health.

 Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood
of developing certain illnesses. Personal behaviour and coping skills – balanced eating,
keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all
affect health.

 Health services - access and use of services that prevent and treat disease influences
health

 Gender - Men and women suffer from different types of diseases at different ages.

 Healthy child development

  Personal health practices and coping skills

 Employment /working condition

EPIDEMIOLOGICAL MEASUREMENT

The basic measurements used in disease frequency are referred to as rates. These are incidence
and prevalence rates.

Definition of Rate

In defining a rate, it is important to know the number of people (denominator) affected in the
entire population (numerator) to be multiplied by 100. Rates help to determine spread. In order to
compare populations of different sizes easily, the rate is usually expressed as the number of
events in an arbitrary total such as 1000 or 100,000.

In general, the rate is equal to the number of cases over the number of population in a given unit
of time:

Rate
number of cases∨events
: × 100,000
population ∈the same area

Incidence Rates (IR)

This is the frequency of the occurrence of events related to a disease such as the onset of
symptoms related to the size of the population. It provides a measure of the rate at which people
without a disease develop the disease during a specified period of time. Incidence rate is
longitudinal and is the fundamental tool for studying the aetiological factors for both acute and
chronic illness.

number of new cases

IR = × a given interval of time
population at risk
Prevalence Rate (PR)

Prevalence rate is defined as the proportion of the population affected by a disease at a particular
time. It therefore measures the number of people in a population who have the disease at a given
time. It is cross– sectional.

number of existing case old + new

PR = ×a given point ∈time
total population at risk

It is clearly evident that a relationship exists between prevalence, incidence and the duration of
the disease. Prevalence is important in determining the workload and planning for facilities (for
example the number of hospital bed required). The relationship changes if the incidence rate is
rapidly changing as in acute epidemic if the average duration of illness changes in response to
treatment.

Other rates to be noted include:

Crude rate – is a rate expressed in terms of the total population. In other words, the numerator
of crude rate is the total population of the area been studied. There are three (3) crude rates
commonly used. These are: crude birth rate, crude death rate and rate of natural population
increase.

A. Crude Birth Rate (CBR) – This is the number of live births to resident in an area in a calendar
year divided by the average population in that population multiplied by 1000

total number of birth∈a year

×1000
mid year population

B. The Crude Death Rate (CDR) - The total number of death in a year divided by the mid- year
population in the area multiplied by 1000

total number of death∈a year

×1000
mid year population

C. Rate of Natural Population Increase (RNPI) – This is the difference between Crude Birth Rate
and Crude Death Rate.
CBR - CDR = RNPI

Specific Rates – This is a rate expressed in terms of a sub-group of a population (i.e.) the
numerator is not the total population but a selected portion of it. The sub-population may be
defined in terms of age or other demographic characteristics like sex, race or as a combination.
Examples are that of age, sex and cause specifics, case fatality, and standardised rate.

number of death∈the age group

Age Specific rate × 1000
number of people aged 15−44 yrs∈a year

number of death∈ women age group 15−44 yrs∈a year

Sex Specific rate = ×1000
number of women aged 15−44 ys∈the population∈a year

Where MMR = Maternal Mortality Rate

STATISTICS

It is a process of collecting, processing, analyzing and reporting of data required for planning and
operating health services. Data can be collected through primary or secondary source. The main
objective is to provide reliable, relevant, adequate, timely and unambiguous information for
health planners who will in turn interpret it for health providers to implement.

The health of a community is assessed by data usage which serves as indicators of the health
status. The main sets of statistics are: morbidity, mortality and service utilization statistics.

Type of Statistics

There are three (3) main types of statistics. These are vital, health and morbidity statistics.

1. VITAL STATISTICS are statistics that records vital events as births, death, marriages,
annulment and divorce obtained at registration centers at local, state and federal levels. The data
are used to generate information for whole groups or entire population.

2. HEALTH STATISTICS are a combination of vital statistics and other data pertinent to health.
In the operation of health services, data can be derived from resources and institutional records.
This can be further explained as being derived from:

o Notification of diseases which is routinely done.

 o Institutions which include hospitals, health centers, dispensaries and private hospitals.
o Special programmes like school health services, maternal and child health, disease
control programme such as tuberculosis and leprosy etc.
o Epidemiological survey which includes the whole population or sample in case of an
epidemic
3. MORBIDITY STATISTICS

This includes data on occurrence and severity of a sickness in a community obtained from
medical health service points.

Statistics from other sectors

There are other sectors apart from health where data can be collected to assist in planning for the
health of people. These include: education, public works such as housing, water supply and
sanitation, agriculture in regards to food production and distribution as well as economic
planning and development which provides the poverty and economic indicator.

Uses of Statistics

Statistics is used for the following reasons among others:

 To measure the health status of people and quantify their health problems
 For health comparisms at local, national and international levels
 For planning, administration and effective management of health services and
programme
 For assessment of health services in relation to the set goals
 For assessing the attitudes and degree of consumers satisfaction to health care
 For health research.